Complete plastic lining of the abdominal cavity during laparoscopic electromechanical morcellation—a promising technique
© Springer-Verlag Berlin Heidelberg 2015
Received: 30 December 2014
Accepted: 14 January 2015
Published: 27 January 2015
The risk of intraperitoneal fragment dissemination of uterine tissue, especially the dissemination of unexpected leiomyosarcoma during electromechanical morcellation, has been increasingly debated during the last year. An improved technique for contained morcellation of uterine tissue inside an insufflated plastic bag during laparoscopy is presented. Twenty-one consecutive contained morcellations were carried out during the summer of 2014, at one institution. Five laparoscopic myomectomies and 16 hysterectomies were performed. Standard laparoscopic equipment was used and a transparent plastic bag was introduced into the abdominal cavity through the umbilical incision mounted on two curved blunt metal probes, which facilitated the placement of the uterine tissue into the bag. Morcellation was carried out inside the plastic bag through the opening in the umbilicus. All 21 morcellations during the study period were successfully performed. The median operative time was 105 min (range 45–180 min) and applying plastic bag and trocar median 10 min (range 4–30 min). Median specimen weight was 560 g (range 80–1265 g). No complications occurred, and no unintended bag perforation was identified. The presented improved contained morcellation technique is feasible in laparoscopic hysterectomy and myomectomy. Larger studies will however be required before the general introduction of the method.
Level of evidence: II-3
Dissemination of benign myoma after electromechanical morcellation is a known complication and is estimated to occur after 0.1 to 1 % of procedures. The fragments of uterine tissue left in the abdomen can cause the implantation of fibroma, infection, pain and the need for reoperation [1–3]. The unintended morcellation of uterine leiomyosarcoma is of even greater concern and is suspected to worsen prognosis [4–6]. It is estimated that between 1:400 and 1:1000 hysterectomy specimens for presumed benign myoma will ultimately be confirmed as leiomyosarcoma . These rare but serious problems not only occur in relation to electromechanical morcellation but probably also during manual morcellation through the vagina or mini-laparotomy. The cleaning and irrigation of the abdominal cavity after traditional electromechanical morcellation are often difficult and time consuming. Morcellation in an inflated transparent plastic bag may reduce these problems. The method may even reduce the risk of the unintended morcellation of the bowel since the bowel is kept away by the plastic bag, which lies flush against all aspects of the abdominal cavity during morcellation.
Morcellation is of great importance in benign gynaecological laparoscopic surgery. In laparoscopic myomectomy and supracervical hysterectomy, it is imperative. In total laparoscopic hysterectomy, morcellation is also required when the uterus, due to size, cannot be removed by the vaginal route. The US Food and Drug Administration (FDA) approved the first electromechanical morcellator in 1995. During the latest years, the risk of intraperitoneal fragment dissemination, especially the dissemination of unexpected leiomyosarcoma, has been debated [1, 4, 6], and the US Food and Drug Administration in April 2014 issued a statement discouraging the use of electromechanical morcellation in most cases . AAGL emphasizes in the report “Morcellation During Uterine Tissue Extraction” from May 2014 the great demand for a contained morcellation system and instrumentation to facilitate the safe removal of specimens . It will be a great setback for minimal invasive gynaecology if laparotomy has to be reintroduced as a standard treatment for many benign gynaecological diseases.
In this report, we describe an innovative feasible technique to place and morcellate uterine and myoma tissue in a specimen retrieval pouch during laparoscopic procedures. Cohen et al. have recently described a technique for contained power morcellation . Our study confirms the feasibility of the technique, presented by Cohen et al., and introduces additional improvement of the minimally invasive specimen retrieval technique.
Materials and methods
Twenty-one consecutive patients underwent uterine tissue morcellation from June to September 2014 for the removal of uterine tissue during laparoscopic myomectomy or laparoscopic hysterectomy at Aleris Hamlet Hospital in Copenhagen, Denmark. All morcellations were performed in a plastic bag, and no laparotomy was performed. The described technique is now a standard procedure at our institution, when removal of uterine tissue requires morcellation during laparoscopy. Informed consent was obtained from all patients for being included in the study.
The preoperative workup to evaluate risk of genital tract cancer included a recent Pap test, endometrial sampling in cases of irregular bleeding and imaging with abdominal and pelvic ultrasonography. Demographic information included patient age, obstetric history, body mass index, physical status, surgical history and indication for surgery. Perioperative information collected prospectively included type of procedure performed, operative time (time from incision to closure), time for placing bag in the abdomen including placement of uterine tissue in the bag and time for placing lateral port in bag (representing extra time used for performing this technique), estimated blood loss (anaesthetic nurse estimate recorded in the operative record), specimen weight, intact status of specimen retrieval pouch (obtained by visual inspection of the bag by the surgeon), length of hospital stay, intraoperative complications, readmission to hospital and reoperation.
Descriptive statistics were performed using Microsoft Office Excel 2013. Median and range are presented for continuous variables. Categorical variables are presented as a number and percentage.
Baseline characteristics of study population (N = 21)
Body mass index (BMI) (kg/m2)
Prior abdominal surgery
Operative characteristics and outcomes of study population (N = 21)
Characteristic or outcome
Supracervical laparoscopic hysterectomy
Total laparoscopic hysterectomy
Adnexal removal or cystectomy
Operative time (min)
Time for applying bag and trocarb
All 21 patients (min)
First 11 patients (min)
Last 10 patients (min)
Estimated blood loss (ml)
Specimen weight (g)
Bag intact at end of procedure
Length of hospital stay
Total laparoscopic hysterectomy was performed in 2 patients, in 12 patients supracervical laparoscopic hysterectomy and in 5 patients a myomectomy. Nearly half of the cases included salpingectomy and 19 % oophorectomy or cystectomy. Major adhesiolysis were performed in 24 % of the cases.
Operative outcomes included mean operation time of 105 min (range 45–180 min). Mean time used for introducing the plastic bag into the abdomen, manipulating the uterine specimen into the bag, insufflating the bag and placement of the 5 mm trocar for gas and optic was 10 min (range 4–30 min). During the first 11 operations, the mean time used was 16 min and the last 10 operations was 7 min. The patients and procedures were not directly comparable; however, the reduction in time consumption indicates a considerable learning curve. Median estimated blood loss was 80 ml and median specimen weight was 560 g (range 80–1265 g). No complications occurred; furthermore, no conversion to laparotomy or repeat surgery and all patients except one were discharged the following morning. One patient stayed 2 days in the hospital for a headache. All retrieval pouches were removed without macroscopic spillage, and the technique was successful with complete morcellation in all 21 cases. No bag perforation was identified, except the 5-mm intended puncture site for inspection and gas insufflation.
In this study, we have demonstrated a feasible method, enabling the gynaecologist to continue minimal invasive surgery without risk of dissemination, even when treating larger uterine myomas. The operating time was not increased, because although insertion of the bag was time consuming (mean 10 min), time at the end was saved because of less need of cleaning and irrigating of the abdominal cavity for remnants of tissue fragments and blood.
The strengths of this study are that all morcellations of uterine tissue performed in the study period were contained in a plastic bag and no laparotomy was needed in the study period. The use of the balloon-tipped trocar prevented leakage from the perforation in the bag, and the visually controlled method of introducing the trocar in the plastic bag prevents bowel perforation during insertion. The procedure was furthermore based on standard laparoscopic equipment and with very low cost. Weaknesses include the small study size and that only two surgeons performed all operations. The deliberate perforation of the plastic bag by the trocar may cause unintended leakage of fluid and tissue despite the “sealing effect” of the balloon trocar. A small in vitro study of contained morcellation in a plastic bag similar to the one used in this study, however, suggests that the technique can effectively decrease or potentially eradicate tissue spillage . A prospective cohort multicentre study, including 200 patients, is planned in Denmark to evaluate the safety and feasibility of the method.
The results in the multicentre cohort study of Cohen et al. , combined with the results of this study, confirm that morcellation of uterine tissue within a specimen retrieval pouch is feasible. Both techniques are based on the use of an inflated large bag made of clear plastic drape film. This results in a large intraabdominal space where bowel is kept away and morcellation is easily performed. The technique will probably be the basis of further development of contained morcellation.
We thank Senior Consultant, MD, PhD, Lars Franch Andersen, for proofreading the manuscript.
Conflict of interest
Henrik Halvor Springborg declares that he has no conflict of interest. Olav Istre declares that he has no conflict of interest.
Details of ethic approval
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation at our institution, Aleris-Hamlet Hospital Scandinavia, and with the Helsinki Declaration of 1975, as revised in 2000 . Informed consent was obtained from all patients for being included in the study.
Details of the contributions of individual authors
Both authors contributed pertinent aspects of the planning, conducting and reporting of the work described in the article.
- Heller DS, Cracchiole B (2014) Peritoneal nodules after laparoscopic surgery with uterine morcellation: review of a rare complication. J Minim Invasive Gynecol 21:384–388View ArticlePubMedGoogle Scholar
- Leren V, Langebrekke A, Qvigstad E (2012) Parasitic leiomyomas after laparoscopic surgery with morcellation. Acta Obstet Gynecol Scand 91:1233–1236View ArticlePubMedGoogle Scholar
- Cucinella G, Granese R, Calagna G, Somigliana E, Perino A (2011) Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases. Fertil Steril 96:e90–e96View ArticlePubMedGoogle Scholar
- Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT et al (2011) The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 122:255–259View ArticlePubMedGoogle Scholar
- Einstein MH, Barakat RR, Chi DS, Sonoda Y, Alektiar KM, Hensley ML et al (2008) Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 18:1065–1070View ArticlePubMedGoogle Scholar
- Della Badia C, Karini H (2010) Endometrial stromal sarcoma diagnosed after uterine morcellation in laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol 17:791–793View ArticlePubMedGoogle Scholar
- Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication, April 17, 2014. (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm)
- AAGL report: Morcellation During uterine tissue extraction, May 2014 (http://www.aagl.org/wp-content/uploads/2014/05/Tissue_Extraction_TFR.pdf)
- Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN et al (2014) Risk of leakage and tissue dissemination with various contained tissue extraction techniques: an in vitro pilot study. J Minim Invasive Gynecol 21:935–939View ArticlePubMedGoogle Scholar
- Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, Fader AN, Shibley T (2014) Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 124(3):491–497View ArticlePubMedGoogle Scholar